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Definition:
Physiologic process Diagnosis: Based on clinical findings Internal Examination (persistent uterine contractions)
LABOR
Phases of Parturition
Uterine Contractions
Progressive Changes in cervical Dilatation and Effacement
Cervical Effacement (>70-80%)
Stages of Labor
Monitoring of Fetal Well-Being During Normal Labor B. Induction of Labor 1. Oxytocin 2. Membrane Sweeping (Stripping) 3. Amniotomy
A.
*Failed Induction
Hypoxia
FHR Monitoring
Labor Induction
Intermittent Auscultation
No evident benefit
Admission CTG
Assessment with documentation prior to starting the induction Induction of labor is a major intervention = only with valid indication (documented)
Assess cervical ripening with the use of Bishops preinduction score system Only in the hospital setting
General Recommendations
Confirmation
Presentation
Parity
Gest. Age
Transverse Breech
Bishops Score
Others
Cephalic
Uterine Activity
Nonstress Test
Induction of Labor
Bishops Score
OXYTOCIN AUGMENTATION
2nd IV line, piggy-backed to the main IV line (close to venipuncture site)
1ml/hr = 1mU/min
Oxytocin
Oxytocin Administration
Uterine Tachysystole
5 contractions in 10mins
Uterine Hypertonus
Single contraction lasting >2mins
NRFS
Hyperstimulation
Stop!
Reposition Continue
(or Initiate EFM) Give O2 mask at 10L/min Notify responsible physician Administer a tocolytic agent Prepare for possible cesaren delivery if fetal pattern remains abnormal Intrauterine Resuscitation Measures
C. Intrapartum Nutrition D. Enema During Labor E. Monitoring the Progress of Labor F. Maternal Position During the First Stage of Labor G. Analgesia and Anesthesia During Labor H. Amniotomy I. Continuous Support During Labor
Alert line monitor the patient closely Action line should do CS or forceps/vacuum delivery
The principles of the partograph include the following:
1. Active phase 3cms 2. Latent phase <8hrs 3. Active phase rate of CD >1cm/hr 4. Lagtime of 4 hrs 5. Vaginal examination (once/4hrs is recommended)
WHO Partograph
Walking
and upright positions reduced length of labor they find most comfortable
Position
Systemic opioids are the most common medications used for labor pain relief
Usually given intramuscularly They allow the parturient to better tolerate the pain of labor Dose-dependent increase in unwanted effects (drowsiness, nausea and vomiting) However, these drugs readily cross the placenta, thus they are associated with risks of respiratory depression and neurobehavioral changes in the newborn
Of all the methods of labor pain relief available in clinical practice, neuraxial analgesia are the most effective methods of intrapartum relief.
This technique offers the highest patient satisfaction and the LEAST depressant effects on the newborn compared with parenteral opioids
Effect on the duration of 1st and 2nd stage labor Epidural increases the risk of CS.
Controversy
Epidural Anesthesia COMBINED SPINAL EPIDURAL ANESTHESIA (CSE) the patients obstetric Can be tailored to meet
needs
Spinal component Should not beonsetas a single entity faster taken Epidural - subsequent labor analgesia
Epidural Anesthesia
Other
techniques:
During labor. A parturients request for pain is a sufficient indication for its use Although meperidine is the most common parenteral opioid used
When not contraindicated, neuraxial analgesia provides the most effective pain relief for labor
RECOMMENDATIONS
RECOMMENDATIONS
Single shot spinal injection spinal opioids with or without local anesthetics may be used to provide less expensive but effective, although time-limited analgesia for labor when VSD is anticipated
Patients in early labor should be given the option of neuraxial analgesia when this service is available
RECOMMENDATIONS
For
RECOMMENDATIONS
The use of low concentrations of volatile anesthesia for labor analgesia is no longer accepted standard of care of labor and vaginal delivery
RECOMMENDATIONS
Amniotomy
Artificial rupture of membranes
Recommendations
Timing Use
Speed up contractions Shorten the length of labor Assumption that shortening the length of labor is beneficial, with little apparent regard for any potential associated adverse effects Clinically indicated to observe the color and amount of amniotic fluid
Complications
Umbilical cord prolapse
enhance progress in the Fetal heart rate decelerations active phase and negate the need for oxytocin Increased ascending infection it may augmentation, but rate increase the risk of Bleeding from fetal or placental vessels chorioamnionitis
Discomfort from the actual procedure
Emotional Support
Elements of Support
Facilitates birth
Enhances the mothers memory of the experience Strengthens mother-infant bonding; increases breastfeeding success Significantly reduces many forms of medical intervention
Types of Provider
Outcomes assessed
26% less likely to give birth by cesarean section 41% less likely to give birth with vacuum extraction or forceps 28% less likely to use any pain medications 33% less likely to be dissatisfied with or negatively rate their birth experience
In settings that do not allow them to bring companions of choice In settings where epidural analgesia is not routine
A.
B.
C.
D. E.
Routine Perineal Shaving Before Delivery Maternal Position During the Second Stage of Labor Alternative Methods of Bearing Down Perineal Support (Hands Poised Versus Hands On) Instrumental Vaginal Delivery
A. Forceps Delivery B. Vacuum Delivery
There is insufficient evidence to recommend perineal shaving for women on admission in labor The aim is to minimize infection risk if there is tearing or cutting of the area between the vagina and anus during birth process Late side effects
Irritation Redness Multiple superficial scratches from the razor Burning and itching of the vulva
Recommendations:
Upright position
Has 4 min shorter interval to delivery Less pain Lower incidence of abnormal fetal heart rate pattern Include sitting, semi-recumbent, kneeling squatting, squatting aided with cushions Benefits: less aortovagal compression, improved fetal alignment, larger anterior, posterior and transverse pelvic outlets
No evidence that the rate of adverse perineal outcomes is affected by different types of bearing down during the 2nd stage of labor.
1. Holding (Valsalva) 2. Spontaneous exhalatory methods of pushing
Perineal trauma is associated with other factors: Supporting Statement: 1. position during delivery The hands oxytocinmethod increased 2. use of poised short maternal expulsive and increased 3. term perineal pain efforts the manual removal of the placenta, 4. presence of suport person however it found no evidence of an effect on the perineal trauma or 3rd/4th degree tears.
Perineal Support
Vaginal delivery
Recommendations
Indications for operative vaginal delivery are not absolute When the fetal head is engaged and the cervix fully dilated, the following indications apply 1. Prolonged 2nd stage Nulliparous women:
Multiparous women:
2. Suspicion of immediate or potential fetal compromise 3. Shortening of the 2nd stage for maternal benefit
Should be done when the criteria for outlet forceps have been met Criteria
Outlet forceps
Scalp is visible at introitus without separating the labia Fetal skull has reached the pelvic floor Sagittal suture is in AP diameter or ROA/LOA or ROP/LOP Fetal head is at or on perineum Rotation does not exceed 45 degrees
Forceps Delivery
Low forceps
Leading point of fetal skull is at station > 2 cm and not on the pelvic floor Rotation is less 45 or less
Midforceps
Station is above +2 cm but head is engaged
High Forceps
Not included in classification
If satisfactory application of forceps cannot be achieved, then the procedure is abandoned and delivery accomplished by use of either vacuum extraction or caesarian section
If application has been achieved but gentle downward pulls do not result in descent, the procedure is abandoned
Recommendations
Only attempt a vacuum assisted delivery when a specific obstetric indication is present The use of soft, bell-shaped vacuum extractor is recommended for uncomplicated, OA deliveries
Vacuum Delivery
Limit vacuum assisted procedures to 2-3 pop-offs. And a total time of 15-30 minutes Failure of an attempted vacuum assisted delivery increases the likelihood of neonatal morbidity; the subsequent use of sequential forceps in this setting should be undertaken with extreme caution Prompt CS delivery is advised after an unsuccessful vacuum assisted procedure.
A.
B. C.
D.
Recommendations
fetal well-being to avoid lacerations
Median Episiotomy increased rate of injury to anal sphincter and rectum. Mediolateral episotomy preferable to median episiotomy Routine Episiotomy does not prevent pelvic floor damage leading to incontinence.
Repair
Polyglycolic acid derivative suture
With minimal reaction to prevent wound inflammation
Purpose
1.
2.
3.
4.
5.
6. 7.
Maternal exhaustion
Indications
Recommendations: Less dyspareunia @ 6weeks Rapid absorption polyglactin most Similar wound breakdown profile as chromic appropriate rarely requires late removal Catgut withdrawn from Earlier UK since 2002 resumption of sexual intercourse Suture Materials for Episiorraphy
Recommendations:
Active Management
1Prophylactic uterotonin within 1 min after the delivery of the baby prior to the delivery of the placenta 2. early cord clamping and cutting 3. Controlled cord traction to deliver the placenta
Giving Uterotonics
Prevent PPH
A. Early Breastfeeding